高流量鼻导管吸氧疗法：重症监护病房的临床实践

High-flow nasal cannula therapy: clinical practice in intensive care units.

作者信息

Besnier Emmanuel, Hobeika Sinad, NSeir Saad, Lambiotte Fabien, Du Cheyron Damien, Sauneuf Bertrand, Misset Benoit, Tamion Fabienne, Schnell Guillaume, Richecoeur Jack, Maizel Julien, Girault Christophe

机构信息

Department of Anaesthesiology and Critical Care, Rouen University Hospital, Rouen, France.

Inserm U1096 EnVi, Normandie Univ, Unirouen, Rouen, France.

出版信息

Ann Intensive Care. 2019 Sep 4;9(1):98. doi: 10.1186/s13613-019-0569-9.

DOI:10.1186/s13613-019-0569-9

PMID:31485841

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6726730/

Abstract

BACKGROUND

Despite the extensive use of high-flow nasal cannula (HFNC) therapy in intensive care units (ICU) for acute respiratory failure (ARF), its daily clinical practice has not been assessed. We designed a regional survey in ICUs in North-west France to evaluate ICU physicians' clinical practice with HFNC.

MATERIALS AND METHODS

We sent an observational survey to ICU physicians from 34 French ICUs over a 6-month period in 2016-2017. The survey included questions regarding the indications and expected efficiency of HFNC, practical aspects of use (initiation, weaning) and satisfaction. Comparisons between junior and senior ICU physicians were performed using a Fischer exact test.

RESULTS

Among the 235 ICU physicians contacted, 137 responded (58.3%) all of whom regularly used HFNC. Hypoxemic ARF was considered a good indication for HFNC by all 137, but only 30% expected HFNC success (i.e., avoiding intubation in at least 60% of cases). Among hypoxemic indications, 30% of juniors considered acute pulmonary edema a good indication versus 74% of seniors (p < 0.0001). Hypercapnic ARF was considered a good indication by 33% with only 2% expecting HFNC success. A need for conventional oxygen therapy ≥ 6 L/min justified HFNC therapy for 40% and ≥ 9 L/min for 39% of responders. 58% of ICU physicians started HFNC therapy with a FiO ≥ 50% and 28% with a gas flow ≥ 50 L/min. Practices for HFNC weaning were heterogeneous: 48% considered a FiO ≤ 30%; whereas, 30% considered a FiO ≤ 30% with a high flow ≤ 20 L/min. Criteria for HFNC failure (i.e., need for intubation) were ventilatory pauses or arrest (97%), persistent hypoxemia (95%), respiratory acidosis (81%), worsening of breathing (95%, 100% of seniors and 86% of juniors, p = 0.003), bronchial congestion (75%) and circulatory failure (61%, 72% of seniors and 44% of juniors, p = 0.007).

CONCLUSION

HFNC is used by ICU physicians in many situations of ARF, despite their relatively low expectations of success, especially in cases of hypercapnia. Clinical practices appear somewhat heterogeneous. Despite the physiological benefit of HFNC, further prospective observational studies are still required on HFNC outcomes and daily practices.

摘要

背景

尽管高流量鼻导管（HFNC）疗法在重症监护病房（ICU）中被广泛用于治疗急性呼吸衰竭（ARF），但其日常临床应用尚未得到评估。我们在法国西北部的ICU开展了一项区域调查，以评估ICU医生使用HFNC的临床实践情况。

材料与方法

2016年至2017年的6个月期间，我们向法国34个ICU的医生发送了一份观察性调查问卷。该问卷包括有关HFNC的适应症、预期疗效、使用的实际方面（启动、撤机）以及满意度等问题。使用Fisher精确检验对初级和高级ICU医生进行比较。

结果

在联系的235名ICU医生中，137人回复（58.3%），他们均经常使用HFNC。所有137人都认为低氧性ARF是HFNC的良好适应症，但只有30%的人预期HFNC会成功（即至少60%的病例避免插管）。在低氧适应症中，30%的初级医生认为急性肺水肿是良好适应症，而高级医生中这一比例为74%（p＜0.0001）。33%的人认为高碳酸血症性ARF是良好适应症，只有2%的人预期HFNC会成功。40%的回复者认为常规氧疗需求≥6L/min是HFNC治疗的合理依据，39%的回复者认为≥9L/min是合理依据。58%的ICU医生以FiO≥50%启动HFNC治疗，28%的医生以气体流量≥50L/min启动。HFNC撤机的做法存在差异：48%的人认为FiO≤30%；而30%的人认为FiO≤30%且高流量≤20L/min。HFNC失败（即需要插管）的标准为通气暂停或停止（97%）、持续性低氧血症（95%）、呼吸性酸中毒（81%）、呼吸恶化（95%，高级医生中为100%，初级医生中为86%，p = 0.003）、支气管充血（75%）和循环衰竭（61%，高级医生中为72%，初级医生中为44%，p = 0.007）。